Can Concierge Medicine for the Few Benefit the Many?

PAULINE W. CHEN, M.D.

Thursday

Aug 26, 2010 at 12:01 AMAug 27, 2010 at 4:18 AM

At a boutique practice at Tufts Medical Center, retainer fees support the general practice, teaching and free health care.

Earlier this summer a friend revealed that for the last nine years she has been a patient in a concierge, or boutique, primary care practice. For $350 each month, she is guaranteed around-the-clock access to her doctor, appointments within 24 hours of calling, longer office visits and the kind of personalized attention and care coordination she felt was missing with all her previous doctors.

“I love this doctor,” she said. “He really knows me.”

She recounted the details of a recent emergency room visit when a call from the doctor saved her from an unnecessary CT scan and admission to the hospital. “I feel like I have a doctor who’s actually thinking about me and talking to other doctors on my behalf,” she added.

But over the course of our conversation, I also discovered that her husband does not share her enthusiasm. He goes to a doctor in a more traditional primary care practice because he’s uncomfortable with the idea that those who can afford it get better care, while those who cannot pay do not. “I just don’t think it’s right,” he told me.

The two of them had agreed to disagree.

Agreeing to disagree has been what most of us, doctor and patient, have done since concierge, or retainer, practices first appeared in the mid-1990s. Developed as an alternative to the constraints of traditional practice, this new model allowed doctors to offer more personalized care that in turn increased patient and professional satisfaction. By decreasing the total number of patients seen in an office from well over 2,000 to as few as 500, doctors could offer longer visits, increased and immediate accessibility, personalized coordination of hospital care and, in some cases, even house calls and accompanied visits to specialists. In return for these services, patients would pay retainer fees, ranging from just under $2,000 to as much as $15,000 per year.

By 2003, according to a national survey, the number of doctors practicing concierge medicine numbered fewer than 200. And while critics raised ethical concerns about the “abandonment” of patients left without primary care physicians while their doctors downsized and the creation of a “two-tiered” system that exacerbated disparities in health care access, little was done to address those concerns. These boutique practices were a relatively rare curiosity, and practitioners were left alone.

But over the years and particularly in recent months, the debate about the ethics of concierge doctoring has grown more heated, with more and more physicians unabashedly lining up to take sides. An editorial in the Annals of Internal Medicine this spring, for example, questioned not only the ethics but also the quality of care delivered in such practices. The writer went on to urge other physicians to abandon “the neutrality with which the medical community has addressed” this issue thus far.

A month later, over a hundred doctors at a national meeting eagerly attended an event billed as a debate on the ethics of retainer medicine. But they weren’t jostling for places to argue the ethics; they wanted to hear about the experiences of physicians who were already successfully practicing concierge medicine and to solicit advice.

As this issue becomes increasingly divisive, it’s hard not to wonder whether it is possible to practice in a way that reconciles concierge medicine with all the ethical concerns.

One group of doctors in Boston believes it is possible. And in an article published this summer in the journal Academic Medicine, they argue that it can be done to the benefit of doctors and all patients, boutique or otherwise.

Since 2004, the primary care physicians at Tufts Medical Center have offered patients the option of being part of either a traditional general medical practice or a retainer practice. Patients in the retainer practice have longer visits, around-the-clock access to one of five physicians, comprehensive wellness and prevention screenings and on-time office appointments within 24 hours of a request. But unlike other boutique practices, the retainer fee of $1,800 per year that these patients pay does not go directly to the doctors’ coffers. Instead, it is used to support the traditional general medical practice, the teaching of medical students and trainees and free care to impoverished patients.

“I feel comfortable that this practice has been set up ethically,” said Dr. David G. Fairchild, senior author of the article and chief medical officer at Tufts Medical Center, who as a primary care physician sees patients at both the retainer practice and the more traditional general medicine practice. “No matter what practice patients are from, we treat them based on their medical need. But we also recognize that there may be a place for a higher level of service.”

That higher level of service, Dr. Fairchild points out, already exists across the country. Many hospitals, for example, have long offered “V.I.P.” rooms or suites or have concierge wards for patients who are willing to pay more during their stay. In the case of the Tufts primary care retainer practice, the differences come down to “add-ons and the environment” that do not affect the quality of care. “Maybe you have a fish tank in one office and not in another,” he said.

This consistency in care across both practices was highlighted in a survey that Dr. Fairchild and his colleagues conducted last year. With responses from more than 300 patients, they found that patients rated the quality of interactions with their doctors similarly regardless of their affiliation. The only significant differences in responses had to do with the services offered — care coordination, physician access and interactions with office staff.

“It’s like going first-class in an airplane,” Dr. Fairchild said. “The experience of people in coach is a little different, but everyone gets to the same place at the same time.”

And at least in this model, more people may be able to board that plane as a result of increased practice revenues. The retainer fees from each new patient can support the physician costs for as many as 50 patients in the traditional practice; and retainer practice patients know from the start that their fees will be used to support teaching, service and free care in the community practice. “Some patients almost feel guilty about wanting this higher level of service,” Dr. Fairchild said. “Using their retainer fees for this type of support helps them see that they are actually making a contribution to teaching and community service, which are the mission of this hospital.”

While Dr. Fairchild is confident that the Tufts retainer practice addresses the ethical concerns of critics, he also acknowledges that concierge medicine is emblematic of larger problems in the health care system.

“This is not how any of us doctors wanted care to be set up,” Dr. Fairchild said, “but the system, as it is now, is broken. Patients are asking for more, doctors are under huge pressures, and there is not enough money in primary care.”

He added, “For the time being, this is a solution that seems to be working for doctors and patients.”

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